NSG 121 HESI Final Exam - Complete Solutions (Answered) Temperature Tactile Differentiation Temperature Sensation. Test temperature sense only if pain
... [Show More] or touch sensation is abnormal. Use one prong of a tuning fork that has been warmed with the hands or use test tubes containing warm and cold water. Ask the patient to close the eyes. Touch the skin with warm or cold objects. Have the patient identify when he or she feels warm or cold. Two Point Discrimination This test is done only if other findings are abnormal. With the patient eyes open, demonstrate what the cotton swabs feel like. Then ask the patient to close the eyes. Hold the blunt end of two cotton swabs approximately 5 cm (2 in.) apart and move them together until the patient feels them as one point (the ends of an opened paperclip may also be used) Romberg Sign In the Romberg test, ask the patient to stand with feet together and arms at sides. Note any swaying (stand close enough to prevent the patient from falling). Ask the patient to close the eyes during the Romberg test for additional assessment. Slight swaying may be normal because visual cues help humans to maintain balance Stuporous Neurological Status Patient is unresponsive and can be aroused only briefly by vigorous, repeated stimulation. Neurological Assessment LOC Spontaneous, Normal Voice, Loud Voice, Tactile, Noxious (pain) Heberden's Nodes Outgrowths that are boney and found on the hands are due to bone spur formation Heberden's Node (most common): found on the distal interphalangeal joint (joint closest to the finger nail) Shoulder ROM Degrees ROM is normal: forward flexion 180 degrees, hyperextension 50 degrees, abduction 180 degrees, adduction 50 degrees, internal rotation 90 degrees, and external rotation 90 degree Muscle Strength Assessment 5/5 normal, complete ROM against gravity & full resistance 4/5 good, complete ROM against gravity & moderate resistance 3/5 fair, complete ROM against gravity 2/5 complete ROM with join supported, cannot perform against gravity 1/5 Trace, muscle contraction but no movement 0/5 no visible muscle contraction Ataxia Assessment Ataxia (irregular uncoordinated movements) or loss of balance may be due to cerebellar disorders, Parkinson disease, multiple sclerosis, strokes, brain tumors, inner ear problems, or medications. gait, stance, sitting, speech disturbance, finger chase, nose-finger, fast alternating hand movements, & heel shin Normal Bowel Sounds There are 5-30 gurgles per minute or one sound every 5-15 seconds in the average adult. Sounds indicate bowel motility and peristalsis. Listen in each quadrant for a full minute. If no sounds are audible, listen for up to 5 minutes Abdomen Auscultation for Bruit Bruits are swishing sounds that indicate turbulent blood flow resulting from constriction or dilation of a tortuous vessel. Bruits in the hepatic area indicate liver cancer or alcoholic hepatitis. Bruits over the aorta or renal arteries indicate partial obstruction of the aorta or renal artery. Borborygmi Increased bowel sounds, called borborygmi, occur with diarrhea and early intestinal obstruction Assessment for Anal Hemorrhoids Observe anus while patient bears down, then lubricate index finger and have patient take deep breath while you insert finger. Should feel full closure around finger. Can be external or internal. Hemorrhoids are usually caused by constant or excessive straining upon defecation Testicular Self Examination Right after hot shower or bath, examine each testicle one at a time Roll testicle between your fingers making note of any lumps or swelling or changes Abdominal Palpation for Elderly Dividing the abdomen into 4 quadrants assists with location of the underlying organs. The elderly are less likely to feel pain with abdominal conditions and do not always present with classic symptoms and laboratory findings. They are more likely to have vague diffuse pain and tend to have a less acute presentation. Allen Test When indicated, perform the Allen test to assess the patency of the collateral circulation of the hands (Fig. 18.9). Ask the patient to make a fist. Occlude the radial and ulnar arteries of the same hand. Have the patient open the hand; release pressure on the ulnar artery. Do the same with the radial artery. [Show Less]